Includes failures of clinical records, prescribing systems or related clinical information processes to create, retain, update, display or otherwise reliably surface safety alerts concerning patients, medicines or treatment.
What is not included
Excludes failures to act on a clearly received alert where the alerting system itself operated as intended.
Excludes non-clinical alert systems such as police, custody, safeguarding or transport systems unless the report directly concerns a clinical safety-alert system.
Excludes generic record-keeping or communication deficiencies that are not specifically tied to the reliability of a clinical safety alert.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England12
Department of Health and Social Care11
Egton Medical Information Systems Limited3
Medicines and Healthcare products Regulatory Agency3
Barts Health NHS Trust2
Care Quality Commission2
Great Western Hospitals NHS Foundation Trust2
Medway NHS Foundation Trust2
NHS Wales2
Proprietary Association of Great Britain2
Royal College of General Practitioners2
Royal Cornwall Hospitals NHS Trust2
Welsh Government2
Adelaide Medical Centre, London1
Alliance Pharmaceuticals Limited1
NHS trust27
Executive non-departmental public body13
Healthcare site13
Ministerial department11
Private limited company6
Health professional body5
Medicines and medical devices regulator3
Company2
Devolved government2
Health and social care service regulator2
Health-system partnership2
Social-care provider2
Trade association2
Community interest company1
Health and care professional regulator1
Reports and published responses 53 reports
See individual reports that have raised this concern, and the actions taken in response
Inner North London
Concerns raised1
Failure to record acknowledged amitriptyline risks in an accessible way for all practitioners
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Tredegar Practice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Tredegar Practice
Identify eligible complex patients, add them to the Risk Management & Care Planning Register, and create corresponding care plans and EMIS alerts.
Greater Lincolnshire
Concerns raised1
Failure of NSAID prescribing software to automatically generate specific warning flags for prescribing considerations and risk factors
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Lincolnshire Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
NHS Lincolnshire Integrated Care Board
Work with all practices to highlight the importance of using OptimiseRx and Eclipse prescribing safety tools.
Avon
Concerns raised1
Lack of a system requiring radiologists to alert clinicians to inconsistencies before finalising their reports
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Bristol NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Bristol NHS Foundation Trust
Implement a discrepancy-management procedure requiring senior radiographer checks, clinician notification when unresolved, and documentation of communications or corrections in reports.
Manchester North
Concerns raised1
Failure to record adverse medication markers on computerised medical records
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
The Croft Shifa Health Centre
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
The Croft Shifa Health Centre
Maintain an electronic medication alert identifying contraindicated or potentially misused medicines and interactions with methadone.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
The Croft Shifa Health Centre
The existing computerised medication alert is considered sufficient to identify potentially contraindicated or misused medicines when prescribing.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cornwall and Isles of Scilly
Concerns raised2
Failure to enter an alert in the digital system when clinical notes have been handwritten
Lack of an EPMA alert requiring review of ongoing suspension of prescribed medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Royal Cornwall Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Royal Cornwall Hospitals NHS Trust
Progress the contracted integrated electronic patient record programme toward operational use from Spring 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Royal Cornwall Hospitals NHS Trust
Because specialties must record inpatient entries in paper notes, no electronic alert is considered necessary for handwritten clinical entries.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Royal Cornwall Hospitals NHS Trust
The prescribing system cannot create suspension alerts, and separate alerts are considered potentially counterproductive because of prescriber alert fatigue.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Royal Cornwall Hospitals NHS Trust
Existing visual prompts on suspended medicines and ward-round drug-chart reviews are considered sufficient to support medication review without a separate alert.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
City of London
Concerns raised1
Failure to alert requesting teams to suspicious radiological findings treated as expected findings
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Barking, Havering and Redbridge University Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Barking, Havering and Redbridge University Hospitals NHS Trust
Alert referrers electronically to expected, unexpected, and newly detected cancers and critical or significant non-cancer findings, with verbal escalation for emergency findings.
Barking, Havering and Redbridge University Hospitals NHS Trust
Launch the Aptvision radiology referral system during the week commencing 30 October 2023.
Barking, Havering and Redbridge University Hospitals NHS Trust
Provide an electronic acknowledgement function for referrers to confirm receipt of finalised radiology reports and urgent notifications, supported by user training.
Barking, Havering and Redbridge University Hospitals NHS Trust
Require specialties to create shared mailboxes receiving imaging-report notifications alongside named consultants’ individual worklists.
Barking, Havering and Redbridge University Hospitals NHS Trust
Add the radiological requesting, review, and expectation process to the Chief Medical Officer’s three-day induction programme for new consultants.
Barking, Havering and Redbridge University Hospitals NHS Trust
Develop a unified North-East London cancer-alert policy through collaborative clinical leadership work.
East London
Concerns raised1
Lack of electronic alerts escalating non-administration of prescribed anticoagulation medication to the medical team
Linked response
Barts Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Barts Health NHS Trust
Update Millennium training so multidisciplinary teams understand and use visual flags to prevent omission of critical medications.
South London
Concerns raised1
Lack of a national risk-flagging system for previous self-harm attendances
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Newcastle upon Tyne and North Tyneside
Concerns raised1
Lack of automatic GP-record alerts for smear-test non-responders
Linked responses
Department of Health and Social Care
EMIS Group
NHS England
The Phoenix Partnership (Leeds) Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
EMIS Group
Undertake an internal review of the concerns raised in the report.
The Phoenix Partnership (Leeds) Ltd
Provide an automatic home-screen alert when a patient is due for a cervical smear, regardless of prior attendance.
The Phoenix Partnership (Leeds) Ltd
Provide a report listing patients due for cervical screening so practices can issue letters, reminders or SMS messages.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
EMIS Group
Existing System alerts and functionality already meet required specifications and the recommendation for automatic cervical screening alerts.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
CQC lacks statutory powers over clinical system providers and therefore cannot directly require improvements in this area.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
GP IT systems automatically display overdue cervical-screening alerts, including for non-responders, so the concern that records lack an alert is incorrect.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
The Phoenix Partnership (Leeds) Ltd
The system cannot alert GPs to non-response because the National Screening Service does not provide that information directly to electronic patient records.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester North
Concerns raised1
Lack of an integrated cross-pharmacy prescription alert system
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
NHS England has no jurisdiction over private healthcare provision, including private online prescribing services.
Outside remitThe respondent said that this matter was outside its role or authority.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.